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Lab Reports - All Decision Trees (depreciated version)

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This page has been updated to:🔬Lab Reports - All Decision Trees
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These decision trees are approved by clinical leads at First 4 Health Group and 20+ other practices. You may have some variation in what you consider ‘standard practice’ - would love to hear about it. Feedback will help us serve you better now, but also help us work out what level of configurability is required as we go forward. We’re thinking about how best to combine messages together to avoid messaging patients several times for individual blood test results - this is coming!

Vitamin D

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Text messages

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If normal Your blood test shows your vitamin D level is normal
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If insufficient Your blood tests show your vitamin D level is slightly reduced. You don't need a prescription but we recommend that you take one 25 microgram tablet once a day (also labelled as 1000iu). You can buy these from any pharmacy.

Notes

  • Under consideration - generate a prescription request to designated pharmacist/clinician.
  • Under consideration - add HIGH vitamin D (>125nmol/L - patient advice)
  • Some guidelines suggest prescription in high risk patients with insufficient vitamin D (25-50) - for now we are not able to support this.

COVID

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Reference

https://cks.nice.org.uk/topics/coronavirus-covid-19/management/confirmed-covid-19/

Text messages

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If positive We’re sorry to hear about your positive COVID test result, you can read about the symptoms and self-care advice here https://www.nhs.uk/covid-19-advice-and-services/

H Pylori

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Reference

https://bnf.nice.org.uk/treatment-summaries/helicobacter-pylori-infection/

Text messages

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If negative Your Helicobacter Pylori test was negative. If you are still experiencing problems please consider contacting the practice. For more information, visit https://patient.info/digestive-health/dyspepsia-indigestion/helicobacter-pylori

Notes

Under consideration - generate a prescription request to designated clinician/pharmacist (pending full record context to check allergies/previous antibiotic use).

Under consideration - task admin team to reorder if invalid sample received - please let us know if you would like this.

Faecal Occult Blood (Bowel screening)

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Reference

https://cks.nice.org.uk/topics/bowel-screening/management/bowel-screening/

Text messages

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If non-response: We've been informed that you have not yet completed your bowel screening test. Please arrange your bowel cancer screening by calling the free helpline on 0800 707 6060. For more information visit: www.nhs.uk/conditions/bowel-cancer-screening
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If abnormal: We received notification that your recent bowel cancer screening test may need further investigation - you will be contacted directly, but if you don't hear anything within 3 weeks, please contact the bowel cancer screening helpline on 0800 7076060.

No message is sent for a normal FOB result - patient will be informed by the national programme.

C-reactive protein (CRP)

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Reference

https://www.ncbi.nlm.nih.gov/books/NBK441843/

Text messages

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If normal Your recent CRP blood test (a marker of inflammation) was normal. To learn more visit https://labtestsonline.org.uk/tests/c-reactive-protein-crp

Urine albumin to creatinine ratio (ACR)

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Reference

https://cks.nice.org.uk/topics/chronic-kidney-disease/diagnosis/initial-investigations/

Text messages

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If normal Your recent urine protein test was normal. To learn more visit https://labtestsonline.org.uk/tests/urine-albumin-creatinine-ratio-or-acr

Vitamin B12

For vitamin B12 results, we check the normal range supplied by the lab, and use this.
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References

https://www.bartshealth.nhs.uk/haematology

https://cks.nice.org.uk/topics/anaemia-b12-folate-deficiency/diagnosis/interpreting-investigation-results/

Text messages

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If normal (according to local lab) Your recent Vitamin B12 blood test was normal, to learn more visit https://labtestsonline.org.uk/tests/vitamin-b12-and-folate

Note April 2024: There’s a new NICE guideline around B12 results. We’re reviewing this guideline currently with our clinical partners - if you have any questions or preferences about how we could implement this guideline please get in touch!

B-Type Natriuretic Peptide Test (BNP)

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Reference

https://cks.nice.org.uk/topics/heart-failure-chronic/diagnosis/how-to-assess/

Text messages

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If normal (<400) Your recent BNP blood test was normal, to learn more visit https://labtestsonline.org.uk/tests/b-type-natriuretic-peptide-bnp-test

Lipids

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Reference

https://cks.nice.org.uk/topics/lipid-modification-cvd-prevention/management/lipid-therapy-primary-prevention-of-cvd/

QOF CHOL002: https://www.england.nhs.uk/wp-content/uploads/2023/03/PRN00289-quality-and-outcomes-framework-guidance-for-2023-24.pdf

Notes

Simple/Normal only for now - advanced lipids including QRISK coming soon! Given the strict guidance around cholesterol it’s unlikely many patients will be considered ‘normal’ by the above algorithm.

Text messages

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If normal (see above) Your recent cholesterol check was normal. To learn more visit https://labtestsonline.org.uk/tests/cholesterol-test

Rheumatoid Factor

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Reference

https://cks.nice.org.uk/topics/rheumatoid-arthritis/diagnosis/investigations-for-suspected-ra/

Text messages

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If normal (less than 10) Your recent rheumatoid factor blood test was normal. To learn more visit https://labtestsonline.org.uk/tests/rheumatoid-factor

Liver function tests

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If normal Your recent liver function blood test was normal. For more information please visit https://labtestsonline.org.uk/tests/liver-blood-tests

ESR (erythrocyte sedimentation rate)

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If normal Your recent ESR blood test (a marker of inflammation) was normal. For more information please visit https://labtestsonline.org.uk/tests/erythrocyte-sedimentation-rate-esr

Note:

ESR increases with age, and some labs don’t account for this in the reported range. We could calculate an age-adjusted upper range of ESR

Adjusted cutoffs are for men = age in years / 2 and for women = age in years + 10 /2

Please get in touch if you would like us to develop this feature.

Renal profile (U&Es)

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If normal Your recent renal profile (kidney) blood test was normal. For more information please visit https://labtestsonline.org.uk/tests/renal-panel

Note

The gut off of normal eGFR > 90 is quite strict, we may be able to relax this in certain groups - interested in your opinion on this - please get in touch!

Coeliac screen

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If normal Your recent coeliac disease screening test suggests you do not have coeliac disease. For more information please visit https://labtestsonline.org.uk/tests/coeliac-disease-tests

Note

This test can result in false negatives if the patient is on a gluten free diet, or is IgA deficient, though most screening labs will now identify IgA deficiency at the same time.

Reference

https://cks.nice.org.uk/topics/coeliac-disease/diagnosis/assessment/

Bone profile

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If normal Your recent bone profile blood test was negative. For more information please visit https://labtestsonline.org.uk/tests/bone-markers

Chlamydia

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If negative Your recent screening test was negative. For details see your NHS app https://www.nhs.uk/nhs-app
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If negative combined Chlamydia & Gonorrhoea test Your recent combined screening test was negative. For details see your NHS app https://www.nhs.uk/nhs-app

Reference

https://labtestsonline.org.uk/tests/chlamydia-test

Gonorrhoea

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If negative Your recent screening test was negative. For details see your NHS app https://www.nhs.uk/nhs-app
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If negative combined Chlamydia & Gonorrhoea test Your recent combined screening test was negative. For details see your NHS app https://www.nhs.uk/nhs-app

Reference

https://labtestsonline.org.uk/tests/gonorrhoea-test

Syphilis

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If negative Your recent screening test was negative. For details see your NHS app https://www.nhs.uk/nhs-app

Reference

https://labtestsonline.org.uk/tests/syphilis-test

HIV screening

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If negative Your recent screening test was negative. For details see your NHS app https://www.nhs.uk/nhs-app

Reference

https://labtestsonline.org.uk/conditions/human-immunodeficiency-virus-hiv

Note

We’re thinking about how best to combine messages together to avoid messaging patients several times for individual blood test results - this is coming!

Complex reports - HbA1c and FBC

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These reports take context from the medical record (diagnoses and previous test results) to inform the decisions taken. This is really exciting as it lets us file a lot of slightly abnormal or near normal tests for you, and do more useful follow-on actions.

Please give this quick video summary a watch - it’s much easier to understand than the writing and diagrams below (6 minutes) 👇

https://www.loom.com/share/d3ffe0b726ab46d7ad2a7ffa516c1f5e?sid=4c14cea9-084d-46e7-88ee-c6108fdda6ff

HbA1c

To be clear, we won’t file any results in the diabetic range, or for a known diabetic patient. But for a normal result in a pre-diabetic or non-diabetic patient we’ll file as normal. For a pre-diabetic result in a pre-diabetic patient, file as stable. For a newly pre-diabetic result in a non-diabetic patient, see below.
To be clear, we won’t file any results in the diabetic range, or for a known diabetic patient. But for a normal result in a pre-diabetic or non-diabetic patient we’ll file as normal. For a pre-diabetic result in a pre-diabetic patient, file as stable. For a newly pre-diabetic result in a non-diabetic patient, see below.

Patient messaging:

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If normal in non-diabetic patient Your blood test for diabetes (HbA1c) shows your blood sugar is in the normal range.
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If normal in pre-diabetic patient Your blood test for diabetes (HbA1c) shows your blood sugar is in the normal range, and below the pre-diabetic range, which is great news! Well done.
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If 42-47 in pre-diabetic patient Your blood test for HbA1c shows your blood sugar is stable in the pre-diabetic range (insert result). This means you are still at an increased risk of developing diabetes. If you haven’t already, please follow this link for a free NHS diabetes prevention programme https://www.england.nhs.uk/diabetes/diabetes-prevention/resources/provider-contact-details/ Please follow a low carbohydrate diet & maintain a healthy weight. We advise annual blood test, blood pressure & weight checks.
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If 42-47 in non-diabetic patient (ie new pre-diabetes) Your blood test for HbA1c shows your blood sugar is now in the pre-diabetic range (insert result). This means you are at risk of developing diabetes. Please follow this link for a free NHS diabetes prevention programme. https://www.england.nhs.uk/diabetes/diabetes-prevention/resources/provider-contact-details/ Please follow a low carbohydrate diet & maintain a healthy weight. We advise annual blood test, blood pressure & weight checks. If you have questions about this please book an appointment.
Question for reviewers - would you like the messages which direct to diabetes education programmes to also include a call-to-action for the patient to contact the practice? E.G. “If you have questions about this please book an appointment.” Please let me know your preferred wording if so!

What do we code?

New pre-diabetes

Pre-diabetes (disorder) 858301000000107

National Health Service Diabetes Prevention Programme invitation 1090701000000104

Existing pre-diabetes invited to education programme:

National Health Service Diabetes Prevention Programme invitation 1090701000000104

FBC - Full Blood Count

The intention here is to file results which are effectively normal but which are flagged by EMIS because some unimportant components fall outside the defined ranges.

Also to catch (i.e. not file) those results where Haemoglobin has dropped by a concerning amount (>30 g/L) from the previous test, while still in the normal range. This is a useful thing for us to flag up that a human might miss!

Please take a look at the decision tree below:

Drop in Haemoglobin is measured from highest result in the last year. Note: Sticky note feature will be enabled after initial release
Drop in Haemoglobin is measured from highest result in the last year. Note: Sticky note feature will be enabled after initial release
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If Normal or Acceptable Your recent full blood count test was normal. To learn more visit https://labtestsonline.org.uk/tests/full-blood-count-fbc

FIT - On request

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Currently enabled on request as some GPs rely on seeing a negative FIT test result to remind them to repeat if symptoms ongoing.
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Reference

https://cks.nice.org.uk/topics/gastrointestinal-tract-lower-cancers-recognition-referral/management/referral-for-suspected-gastrointestinal-tract-lower-cancer/

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If negative Your FIT (poo stick) test was normal, for more information please visit www.patient.info/cancer/colon-rectal-bowel-cancer-colorectal/faecal-occult-blood-test. If you still have symptoms or concerns please consider contacting the practice.

Notes

  • Under consideration - reorder test automatically.
  • Under consideration - generate eRS referral for final sign off by duty/designated clinician, arrange urgent patient appointment.
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